EIN: 850224409
UEI: GM5RQCKU6TN1
Audited by: SJT Group LLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 19, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by November 19, 2026 (77 days from today).
What is a management decision? →FCCH’s 2024 single audit reporting package was not submitted by the due date of September 30, 2025. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time.
Show full finding ▾Hide full finding ▴2024-004—Late Audit Report Federal program information: Funding agency: U.S. Department of Health and Human Services Title: All Assistance Listing Number (ALN): All Award number and year: All Criteria: According to 2 CFR Part 200.512, the annual single audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor's report or nine months after the end of the audit period (September 30, 2024). Condition: FCCH’s 2024 single audit reporting package was not submitted by the due date of September 30, 2025. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time.
2024-004—Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: May 31, 2026
2023-004
For one of 30 medical claims tested, the amount billed did not agree to FCCH’s fee schedule for the procedures performed after applying FCCH’s sliding fee discount from the Sliding Fee Discount Program (SFDP). Questioned Costs: None Context: One of 30 medical claims tested. Cause: At the patient’s initial visit, they did not bring in income documentation to qualify for a sliding fee discount. However, the patient did bring in the income documentation within 30 days of the date of service, but the billing department was not notified of this information so that the sliding fee discount could be applied. Effect: FCCH is not in compliance with 42 CFR Part 51c.303(f). Additionally, FCCH is not in compliance with its Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Auditor’s Recommendations: FCCH should implement its established policies and procedures which require adherence to the approved schedule of fees for services and discounts. FCCH should also consider performing its own review of medical claims billed to determine the prevalence of these errors. Management’s Response: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence.
Show full finding ▾Hide full finding ▴2024-005—Special Tests and Provisions—Sliding Fee Discount Program Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224 Award number and year: H80CS00202 (1/1/2024 – 12/31/2024) Criteria: According to 42 CFR Part 51c.303(f) and FCCH’s Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures, a community health center must have prepared a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay, provided that such schedule of discounts shall provide for a full discount to individuals and families with annual incomes at or below those set forth in the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2); and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines. Condition: For one of 30 medical claims tested, the amount billed did not agree to FCCH’s fee schedule for the procedures performed after applying FCCH’s sliding fee discount from the Sliding Fee Discount Program (SFDP). Questioned Costs: None Context: One of 30 medical claims tested. Cause: At the patient’s initial visit, they did not bring in income documentation to qualify for a sliding fee discount. However, the patient did bring in the income documentation within 30 days of the date of service, but the billing department was not notified of this information so that the sliding fee discount could be applied. Effect: FCCH is not in compliance with 42 CFR Part 51c.303(f). Additionally, FCCH is not in compliance with its Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Auditor’s Recommendations: FCCH should implement its established policies and procedures which require adherence to the approved schedule of fees for services and discounts. FCCH should also consider performing its own review of medical claims billed to determine the prevalence of these errors. Management’s Response: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence.
2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2026
FAC accepted this audit on January 19, 2026 — management decision was due July 19, 2026.
FCCH’s 2023 single audit reporting package was not submitted by the due date of September 30, 2024. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnoveer has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time.
Show full finding ▾Hide full finding ▴2023-004—Late Audit Report Federal program information: Funding agency: All Title: All Assistance Listing Number (ALN): All Award number and year: All Criteria: According to 2 CFR Part 200.512, the annual single audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor's report or nine months after the end of the audit period (September 30, 2024). Condition: FCCH’s 2023 single audit reporting package was not submitted by the due date of September 30, 2024. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnoveer has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time.
2023-004 – Late Audit Report Corrective Action: FCCH leadership inherited a situation in which the organization was woefully behind in its accounting records. The existing team has relentlessly pursued getting caught up. Turnover has hampered our efforts, yet we remain committed to the task. We are committed to continuing the effort to become fully compliant and to submit our 2025 audit on time. The FCCH Board of Directors shall ensure accountability for completing all audits in the future on time. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2026
2022-006
FAC accepted this audit on September 5, 2024 — management decision was due March 5, 2025.
For 14 of 25 nonpayroll transactions tested, there was no evidence available supporting that the items ordered had been received by the program/location for which they were ordered. Questioned Costs: $31,600. Context: 14 of 25 nonpayroll transactions tested were not adequately documented. Cause: FCCH has not developed policies and procedures requiring documentation that goods purchased have been received by the program/location prior to payments being approved and remitted to vendors. Effect: FCCH may not be able to demonstrate that some costs charged to federal programs are allowable. Auditor’s Recommendations: FCCH should implement its approved policies and procedures to ensure that amounts charged to federal programs are allowable and properly documented. Additionally, FCCH should consider updating its policies and procedures to require documentation that goods purchased have been received by the program/location prior to payments being remitted to vendors. Management’s Response: FCCH management shall promote accountability for following approved policies and procedures over employee records and accounts payable. Receiving policies and processes, including documentation for receiving inventory and equipment, should be developed and then implemented. All involved personnel should be trained in the new policies.
Show full finding ▾Hide full finding ▴2022-004—Allowable Costs Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224, 93.527 Award number and year: H80C00202 (1/1/2022–12/31/2022) H8ECS37778 (5/1/2020–4/30/2022) H8FCS40603 (4/1/2021–3/31/2023) C8ECS43815 (9/15/2021–9/14/2024) Criteria: According to 2 CFR Part 225, to be allowable under federal awards, costs must be adequately documented, be necessary and reasonable for the performance of the federal award and be allocable thereto under the principles in 2 CFR Part 200, Subpart E. Additionally, non-Federal entities receiving federal awards should establish and maintain internal control designed to reasonably ensure compliance with Federal laws, regulations and program compliance requirements. Condition: For 14 of 25 nonpayroll transactions tested, there was no evidence available supporting that the items ordered had been received by the program/location for which they were ordered. Questioned Costs: $31,600. Context: 14 of 25 nonpayroll transactions tested were not adequately documented. Cause: FCCH has not developed policies and procedures requiring documentation that goods purchased have been received by the program/location prior to payments being approved and remitted to vendors. Effect: FCCH may not be able to demonstrate that some costs charged to federal programs are allowable. Auditor’s Recommendations: FCCH should implement its approved policies and procedures to ensure that amounts charged to federal programs are allowable and properly documented. Additionally, FCCH should consider updating its policies and procedures to require documentation that goods purchased have been received by the program/location prior to payments being remitted to vendors. Management’s Response: FCCH management shall promote accountability for following approved policies and procedures over employee records and accounts payable. Receiving policies and processes, including documentation for receiving inventory and equipment, should be developed and then implemented. All involved personnel should be trained in the new policies.
2022-004—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedures shall be reviewed to ensure adequacy of measures to ensure compliance. FCCH leadership shall also be trained in the elements of allowable cost principles. Person Responsible: Shawna Gonzales, Chief Financial Officer and Abigail Jackson, Human Resources Director Completion Date: December 31, 2024
2021-006
Two of four SF-425 reports tested were submitted past the deadline after the end of each period. Questioned Costs: None Context: Two of four SF-425 reports tested for these awards. Cause: FCCH experienced turnover in the accounting department in key positions in recent years and, as a result, approved policies and procedures were not followed. Additionally, program personnel did not review and approve the reports for submission in a timely manner. Effect: FCCH is not in compliance with reporting requirements for these awards. Auditor’s Recommendations: FCCH should implement its Grants/Contracts Submission and Management Policies and Procedures to ensure all program reports are properly completed and submitted by the required due dates. Management’s Response: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Access to reporting portals shall be granted to and maintained by appropriate personnel so that turnover does not impair compliance.
Show full finding ▾Hide full finding ▴2022-005—Reporting Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224, 93.527 Award number and year: C8ECS43815 (9/15/2021–9/14/2024) H8FCS40603 (4/1/2021–3/31/2023) Criteria: Federal Financial Reports (SF-425) are required to be submitted to the granting agency according to the Notice of Awards for these programs. Condition: Two of four SF-425 reports tested were submitted past the deadline after the end of each period. Questioned Costs: None Context: Two of four SF-425 reports tested for these awards. Cause: FCCH experienced turnover in the accounting department in key positions in recent years and, as a result, approved policies and procedures were not followed. Additionally, program personnel did not review and approve the reports for submission in a timely manner. Effect: FCCH is not in compliance with reporting requirements for these awards. Auditor’s Recommendations: FCCH should implement its Grants/Contracts Submission and Management Policies and Procedures to ensure all program reports are properly completed and submitted by the required due dates. Management’s Response: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Access to reporting portals shall be granted to and maintained by appropriate personnel so that turnover does not impair compliance.
2022-005—Reporting Corrective Action: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024
2021-008
FCCH’s 2022 single audit reporting package was not submitted by the due date of September 30, 2023. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership shall ensure accountability for completing audits and submitting reports in a timely manner. Now that vacant positions in the accounting department have been filled, reconciliations are being caught up as efficiently as possible so that delinquent audits can also be conducted and concluded. Furthermore, the FCCH Board of Directors is undergoing compliance training, and they shall also ensure accountability for completing audits in the future once the audits are caught up.
Show full finding ▾Hide full finding ▴2022-006—Late Audit Report Federal program information: Funding agency: All Title: All Assistance Listing Number (ALN): All Award number and year: All Criteria: According to 2 CFR Part 200.512, the annual single audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor's report or nine months after the end of the audit period (September 30, 2022). Condition: FCCH’s 2022 single audit reporting package was not submitted by the due date of September 30, 2023. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership shall ensure accountability for completing audits and submitting reports in a timely manner. Now that vacant positions in the accounting department have been filled, reconciliations are being caught up as efficiently as possible so that delinquent audits can also be conducted and concluded. Furthermore, the FCCH Board of Directors is undergoing compliance training, and they shall also ensure accountability for completing audits in the future once the audits are caught up.
2022-006—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: December 31, 2024
2021-009
FAC accepted this audit on June 27, 2024 — management decision was due December 27, 2024.
For two of 25 payroll transactions tested, there was no support for the approved pay rate of the employee. For nine of 25 nonpayroll transactions tested, there was no evidence available supporting that the items ordered had been received by the program/location for which they were ordered. Questioned Costs: Undeterminable for the payroll transactions tested and $46,643 for the nonpayroll transactions tested. Context: Two of 25 payroll transactions tested and nine of 25 nonpayroll transactions tested were not adequately documented. Cause: FCCH is not following its approved policies and procedures over personnel records and accounts payable. Additionally, FCCH has not developed policies and procedures requiring documentation that goods purchased have been received by the program/location prior to payments being approved and remitted to vendors. Effect: FCCH may not be able to demonstrate that some costs charged to federal programs are allowable. Auditor’s Recommendations: FCCH should implement its approved policies and procedures to ensure that amounts charged to federal programs are allowable and properly documented. Additionally, FCCH should consider updating its policies and procedures to require documentation that goods purchased have been received by the program/location prior to payments being remitted to vendors. Management’s Response: FCCH management shall promote accountability for following approved policies and procedures over employee records and accounts payable. Receiving policies and processes, including documentation for receiving inventory and equipment, should be developed and then implemented. All involved personnel should be trained in the new policies.
Show full finding ▾Hide full finding ▴2021-006—Allowable Costs Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224, 93.527 Award number and year: H80C00202 (1/1/2021–12/31/2021) H8DCS36371 (4/1/2020–3/31/2021) H8ECS37778 (5/1/2020–4/30/2021) H8F40603 (4/1/2021–3/31/2023) Criteria: According to 2 CFR Part 225, to be allowable under federal awards, costs must be adequately documented, be necessary and reasonable for the performance of the federal award and be allocable thereto under the principles in 2 CFR Part 200, Subpart E. Additionally, non-Federal entities receiving federal awards should establish and maintain internal control designed to reasonably ensure compliance with Federal laws, regulations and program compliance requirements. Condition: For two of 25 payroll transactions tested, there was no support for the approved pay rate of the employee. For nine of 25 nonpayroll transactions tested, there was no evidence available supporting that the items ordered had been received by the program/location for which they were ordered. Questioned Costs: Undeterminable for the payroll transactions tested and $46,643 for the nonpayroll transactions tested. Context: Two of 25 payroll transactions tested and nine of 25 nonpayroll transactions tested were not adequately documented. Cause: FCCH is not following its approved policies and procedures over personnel records and accounts payable. Additionally, FCCH has not developed policies and procedures requiring documentation that goods purchased have been received by the program/location prior to payments being approved and remitted to vendors. Effect: FCCH may not be able to demonstrate that some costs charged to federal programs are allowable. Auditor’s Recommendations: FCCH should implement its approved policies and procedures to ensure that amounts charged to federal programs are allowable and properly documented. Additionally, FCCH should consider updating its policies and procedures to require documentation that goods purchased have been received by the program/location prior to payments being remitted to vendors. Management’s Response: FCCH management shall promote accountability for following approved policies and procedures over employee records and accounts payable. Receiving policies and processes, including documentation for receiving inventory and equipment, should be developed and then implemented. All involved personnel should be trained in the new policies.
2021-006—Allowable Costs Corrective Action: FCCH Management shall conduct training of human resource and accounting personnel to ensure they understand the requirement for allowable costs under 2 CFR Part 225 and shall follow the principles in 2 CFR Part 200, Subpart E. Current policies and procedures shall be reviewed to ensure adequacy of measures to ensure compliance. FCCH leadership shall also be trained in the elements of allowable cost principles. Person Responsible: Shawna Gonzales, Chief Financial Officer and Abigail Jackson, Human Resources Director Completion Date: December 31, 2024
For two of 40 medical claims tested, the amount billed did not agree to FCCH’s fee schedule for the procedures performed during the clinic visit. One claim was billed to a third-party payer, and one claim was billed to the patient under FCCH’s sliding fee discount program (SFDP). Questioned Costs: None Context: Two of 40 medical claims tested. Cause: FCCH experienced significant turnover in key positions in the billing department, including the Revenue Cycle Manager, and approved policies and procedures were not followed. Effect: FCCH is not in compliance with 42 CFR Part 51c.303(f). Additionally, FCCH is not in compliance with its Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Auditor’s Recommendations: FCCH should implement its established policies and procedures which require adherence to the approved schedule of fees for services and discounts. FCCH should also consider performing its own review of medical claims billed to determine the prevalence of these errors. Management’s Response: FCCH Management shall ensure adherence to established policies and procedures. Charges shall follow the schedule of fees and services, and discount programs shall be administered accurately so that compliance with 42 CFR Part 51c.303(f) and Sliding Fee Discount policies are maintained. FCCH shall also perform a review of its medical claims billed, determine the prevalence of errors, and educate staff to improve accuracy.
Show full finding ▾Hide full finding ▴2021-007—Special Tests and Provisions—Sliding Fee Discount Program Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224, 93.527 Award number and year: H80C00202 (1/1/2021–12/31/2021) H8DCS36371 (4/1/2020–3/31/2021) H8ECS37778 (5/1/2020–4/30/2021) H8F40603 (4/1/2021–3/31/2023) Criteria: According to 42 CFR Part 51c.303(f) and FCCH’s Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures, a community health center must have prepared a schedule of fees or payments for the provision of its services designed to cover its reasonable costs of operation and a corresponding schedule of discounts adjusted on the basis of the patient's ability to pay, provided that such schedule of discounts shall provide for a full discount to individuals and families with annual incomes at or below those set forth in the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. 9902(2); and for no discount to individuals and families with annual incomes greater than twice those set forth in such guidelines. Condition: For two of 40 medical claims tested, the amount billed did not agree to FCCH’s fee schedule for the procedures performed during the clinic visit. One claim was billed to a third-party payer, and one claim was billed to the patient under FCCH’s sliding fee discount program (SFDP). Questioned Costs: None Context: Two of 40 medical claims tested. Cause: FCCH experienced significant turnover in key positions in the billing department, including the Revenue Cycle Manager, and approved policies and procedures were not followed. Effect: FCCH is not in compliance with 42 CFR Part 51c.303(f). Additionally, FCCH is not in compliance with its Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Auditor’s Recommendations: FCCH should implement its established policies and procedures which require adherence to the approved schedule of fees for services and discounts. FCCH should also consider performing its own review of medical claims billed to determine the prevalence of these errors. Management’s Response: FCCH Management shall ensure adherence to established policies and procedures. Charges shall follow the schedule of fees and services, and discount programs shall be administered accurately so that compliance with 42 CFR Part 51c.303(f) and Sliding Fee Discount policies are maintained. FCCH shall also perform a review of its medical claims billed, determine the prevalence of errors, and educate staff to improve accuracy.
2021-007— Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: FCCH management shall ensure adherence to established policies and procedures requiring accurate patient billing, including application of eligible discounts. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2024
Three of six SF-425 reports tested were submitted past the deadline after the end of each period. Questioned Costs: None Context: Three of six SF-425 reports tested for these awards. Cause: FCCH experienced turnover in the accounting department in key positions in recent years and, as a result, approved policies and procedures were not followed. Additionally, program personnel did not review and approve the reports for submission in a timely manner. Effect: FCCH is not in compliance with reporting requirements for these awards. Auditor’s Recommendations: FCCH should implement its Grants/Contracts Submission and Management Policies and Procedures to ensure all program reports are properly completed and submitted by the required due dates. Management’s Response: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Access to reporting portals shall be granted to and maintained by appropriate personnel so that turnover does not impair compliance.
Show full finding ▾Hide full finding ▴2021-008—Reporting Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Health Center Cluster Assistance Listing Number (ALN): 93.224, 93.527 Award number and year: H80C00202 (1/1/2021–12/31/2021) H8ECS37778 (5/1/2020–4/30/2021) H8F40603 (4/1/2021–3/31/2023) Criteria: Federal Financial Reports (SF-425) are required to be submitted to the granting agency according to the Notice of Awards for these programs. Condition: Three of six SF-425 reports tested were submitted past the deadline after the end of each period. Questioned Costs: None Context: Three of six SF-425 reports tested for these awards. Cause: FCCH experienced turnover in the accounting department in key positions in recent years and, as a result, approved policies and procedures were not followed. Additionally, program personnel did not review and approve the reports for submission in a timely manner. Effect: FCCH is not in compliance with reporting requirements for these awards. Auditor’s Recommendations: FCCH should implement its Grants/Contracts Submission and Management Policies and Procedures to ensure all program reports are properly completed and submitted by the required due dates. Management’s Response: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Access to reporting portals shall be granted to and maintained by appropriate personnel so that turnover does not impair compliance.
2021-008—Reporting Corrective Action: FCCH shall implement its Grants/Contracts Submission and Management Policies and Procedures and educate staff to ensure all program reports are properly completed and submitted by the required due dates. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024
2020-004
FCCH’s 2021 single audit reporting package was not submitted by the due date of September 30, 2022. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership shall ensure accountability for completing audits and submitting reports in a timely manner. Now that vacant positions in the accounting department have been filled, reconciliations are being caught up as efficiently as possible so that delinquent audits can also be conducted and concluded.
Show full finding ▾Hide full finding ▴2021-009—Late Audit Report Federal program information: Funding agency: All Title: All Assistance Listing Number (ALN): All Award number and year: All Criteria: According to 2 CFR Part 200.512, the annual single audit must be completed and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor's report or nine months after the end of the audit period (September 30, 2022). Condition: FCCH’s 2021 single audit reporting package was not submitted by the due date of September 30, 2022. Questioned Costs: None Context: N/A Cause: FCCH experienced turnover in the accounting department in key positions in recent years, which caused significant delays in completion of the year-end reconciliations of the financial statements and the schedule of expenditures of federal awards. Effect: FCCH was unable to completely reconcile certain general ledger accounts timely, which resulted in the audit not being completed within the reporting deadline. Auditor’s Recommendations: FCCH should implement its approved policies and procedures and complete the year-end account reconciliations in a timely manner to ensure the timely completion of the audit and submission of the single audit reporting package. Management’s Response: FCCH leadership shall ensure accountability for completing audits and submitting reports in a timely manner. Now that vacant positions in the accounting department have been filled, reconciliations are being caught up as efficiently as possible so that delinquent audits can also be conducted and concluded.
2021-009—Late Audit Report Corrective Action: FCCH shall implement its approved policies and procedures that govern year-end reconciliations and closing procedures so that records are maintained in an audit-ready manner. Person Responsible: Shawna Gonzales, Chief Financial Officer Completion Date: September 30, 2024
FAC accepted this audit on July 25, 2023 — management decision was due January 25, 2024.
We noted FCCH is not in compliance with requirements related to procurement and suspension and debarment. Questioned costs: Unknown Context: For 6 of 6 procurement transactions totaling approximately $330.7K, FCCH was unable to provide records sufficient to detail the history of procurement including three quotes from qualified sources. Also, FCCH did not perform the required verification checks prior to entering into covered transactions. Cause: Management oversight. FCCH lacks established internal controls and procedures over procurement and suspension and debarment. Effect: The auditor noted instances of noncompliance. Noncompliance results in possible federal funds provided to ineligible vendors. Recommendation: We recommend FCCH design controls and procedures to ensure compliance with federal procurement regulations. We recommend FCCH implement an adequate review process to ensure the exclusion check is completed, results of the check are reviewed and approved with the approval documented, and the results of the check maintained in the procurement file. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services Federal Program Name: Health Center Program Cluster Assistance Listing Numbers: 93.224 and 93.527 Federal Award Identification Number and Year: H80CS00202 ? 2020, H8CCS35003 ? 2020, and H8DCS36371 ? 2020 Award Period: January 1, 2002 through December 31, 2020, March 15, 2020 through March 14, 2021, and April 1, 2020 through March 31,2021 Type of Finding: ? Material Weakness in Internal Control over Compliance ? Material Noncompliance (Modified Opinion) Criteria or specific requirement: According to ? 75.327 General procurement standards of 45 CFR Part 75, the non-federal entity must maintain records sufficient to detail the history of procurement. These records will include but are not necessarily limited to the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. According to ? 75.329 Procurement procedures of 45 CFR Part 75, if small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources. According to FCCH's Procurement Policies and Procedures, quotes must be obtained from at least three vendors deemed to be qualified (due to reputation in the respective field or prior experience with the vendor). According to ? 180.300 of Subpart C - Responsibilities of Participants Regarding Transactions Doing Business With Other Persons of 2 CFR Part 180, when you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified. You do this by: (a) Checking SAM Exclusions; or (b) Collecting a certification from that person; or (c) Adding a clause or condition to the covered transaction with that person. Condition: We noted FCCH is not in compliance with requirements related to procurement and suspension and debarment. Questioned costs: Unknown Context: For 6 of 6 procurement transactions totaling approximately $330.7K, FCCH was unable to provide records sufficient to detail the history of procurement including three quotes from qualified sources. Also, FCCH did not perform the required verification checks prior to entering into covered transactions. Cause: Management oversight. FCCH lacks established internal controls and procedures over procurement and suspension and debarment. Effect: The auditor noted instances of noncompliance. Noncompliance results in possible federal funds provided to ineligible vendors. Recommendation: We recommend FCCH design controls and procedures to ensure compliance with federal procurement regulations. We recommend FCCH implement an adequate review process to ensure the exclusion check is completed, results of the check are reviewed and approved with the approval documented, and the results of the check maintained in the procurement file. Views of responsible officials: There is no disagreement with the audit finding.
Procurement, Suspension and Debarment Recommendation: CLA recommends FCCH design controls and procedures to ensure compliance with federal procurement regulations. Additionally, CLA recommends FCCH implement an adequate review process to ensure the exclusion check is completed, results of the check are reviewed and approved with the approval documented, and the results of the check maintained in the procurement file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: FCCH is retraining procurement staff to ensure compliance with federal regulations. Pertinent policies and procedures shall be reviewed, updated, and then discussed with procurement staff and oversight personnel. Exclusion checks are to be documented, approved, and maintained in the procurement files. Responsible Party: The CFO is responsible for ensuring procurement compliance with federal regulations. The planned completion date for training and approvals is August 31, 2023.
We noted FCCH is not in compliance with reporting requirements. Questioned costs: None Context: During our testing, we noted the following matters related to reporting. Assistance Listing Numbers 93.527 and 93.224 FCCH was unable to provide documentation that supported the following key line items reported on the 2020 UDS Report. ? Total number of patients (Table 4, Line 6, Column a) ? Total accrued medical staff ad other medical cost after allocation of overhead excluding medical lab and x-ray cost (Table 8A, Line 1, Column c and Table 8A, Line 3, Column c) ? Non-nursing medical visits (excluding nursing (RN) visits) (Table 5, Line 15, Column b and Table 5, Line 11, Column b) Assistance Listing Number 11.300 ? For the Form SF-425 financial reports for the periods ending March 31 and September 30, federal expenditures did not agree to the expenditure detail in an approximate amount of $141.3K and $484.7K, respectively. ? No approval for one of the five Form SF-271 financial reports submitted during the year. ? One of the five Form SF-271 financial reports submitted during the year not provided to us. Cause: Management oversight. FCCH lacks established internal controls and procedures over financial grant management to ensure submitted reports are complete, agree to supporting spreadsheets, and are properly maintained in the files of FCCH. Effect: The auditor noted instances of noncompliance. Noncompliance results in delayed reimbursement of eligible federal expenditures. Potential loss of federal funding. Recommendation: We recommend FCCH design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of FCCH. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Health and Human Services U.S. Department of Commerce Federal Program Name: Health Center Program Cluster Investments for Public Works and Economic Development Facilities Assistance Listing Numbers: 93.224 and 93.527 11.300 Federal Award Identification Number and Year: H80CS00202 ? 2019 08-01-05139 ? 2016 Award Period: January 1, 2002 through December 31, 2020 October 2, 2016 through October 1, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: According to ? 75.302 Financial management and standards for financial management systems of 45 CFR Part 75, the non-federal entity?s financial management systems, including records documenting compliance with federal statutes, regulations, and the terms and conditions of the federal award, must be sufficient to permit the preparation of reports required by general and program-specific terms and conditions. Further, the financial management system of each non-federal entity must provide accurate, current, and complete disclosure of the financial results of each federal award or program in accordance with the reporting requirements. According to ? 75.303 Internal controls of 45 CFR Part 75, the non-federal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition: We noted FCCH is not in compliance with reporting requirements. Questioned costs: None Context: During our testing, we noted the following matters related to reporting. Assistance Listing Numbers 93.527 and 93.224 FCCH was unable to provide documentation that supported the following key line items reported on the 2020 UDS Report. ? Total number of patients (Table 4, Line 6, Column a) ? Total accrued medical staff ad other medical cost after allocation of overhead excluding medical lab and x-ray cost (Table 8A, Line 1, Column c and Table 8A, Line 3, Column c) ? Non-nursing medical visits (excluding nursing (RN) visits) (Table 5, Line 15, Column b and Table 5, Line 11, Column b) Assistance Listing Number 11.300 ? For the Form SF-425 financial reports for the periods ending March 31 and September 30, federal expenditures did not agree to the expenditure detail in an approximate amount of $141.3K and $484.7K, respectively. ? No approval for one of the five Form SF-271 financial reports submitted during the year. ? One of the five Form SF-271 financial reports submitted during the year not provided to us. Cause: Management oversight. FCCH lacks established internal controls and procedures over financial grant management to ensure submitted reports are complete, agree to supporting spreadsheets, and are properly maintained in the files of FCCH. Effect: The auditor noted instances of noncompliance. Noncompliance results in delayed reimbursement of eligible federal expenditures. Potential loss of federal funding. Recommendation: We recommend FCCH design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of FCCH. Views of responsible officials: There is no disagreement with the audit finding.
Reporting Recommendation: CLA recommends FCCH design controls and procedures to ensure submitted reports and the documentation used to prepare the reports are properly maintained in the files of FCCH. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: FCCH shall retrain accounting and grants staff to ensure compliance with internal controls and procedures for submitting reports. Policies and procedures shall be reviewed, updated, and then reviewed with appropriate staff and oversight personnel. All documentation shall be reviewed prior to submitting reports. Responsible Party: The CFO and Grants Director are responsible for ensuring compliance with grant and contract reporting and documentation maintenance. The planned completion date for updating procedures and training staff is September 30, 2023.
Lack of documentation to support FCCH met the matching requirement. Questioned costs: None Context: Actual lien not provided to us to test EDA's interest in the real property remaining in effect for 20 years. Cause: Management oversight. FCCH lacks established internal controls and procedures over financial grant management to ensure supporting documentation is properly maintained in the files of FCCH evidencing compliance with the terms and conditions of the federal award. Effect: The auditor noted an instance of noncompliance. Noncompliance results in potential repayment or loss of federal funding. Recommendation: We recommend FCCH design controls and procedures to ensure supporting documentation is properly maintained in the files of FCCH evidencing compliance with the terms and conditions of the federal award. Views of responsible officials: There is no disagreement with the audit finding.
Show full finding ▾Hide full finding ▴Federal Agency: U.S. Department of Commerce Federal Program Name: Investments for Public Works and Economic Development Facilities Assistance Listing Number: 11.300 Federal Award Identification Number and Year: 08-01-05139 - 2016 Award Period: October 2, 2016 through October 1, 2021 Type of Finding: ? Significant Deficiency in Internal Control over Compliance ? Other Matters Criteria or specific requirement: According to ? 75.303 Internal controls of 45 CFR Part 75, the nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. According to the terms and conditions of the federal award, the statement of EDA's interest must be perfected and placed of record in the real property records of the jurisdiction in which the property is located, all in accordance with local law. The lien, covenant or other statement of EDA's interest must remain in effect throughout the useful life of the Project which is determined to be 20 years. Condition: Lack of documentation to support FCCH met the matching requirement. Questioned costs: None Context: Actual lien not provided to us to test EDA's interest in the real property remaining in effect for 20 years. Cause: Management oversight. FCCH lacks established internal controls and procedures over financial grant management to ensure supporting documentation is properly maintained in the files of FCCH evidencing compliance with the terms and conditions of the federal award. Effect: The auditor noted an instance of noncompliance. Noncompliance results in potential repayment or loss of federal funding. Recommendation: We recommend FCCH design controls and procedures to ensure supporting documentation is properly maintained in the files of FCCH evidencing compliance with the terms and conditions of the federal award. Views of responsible officials: There is no disagreement with the audit finding.
Matching Recommendation: CLA recommends FCCH design controls and procedures to ensure supporting documentation is properly maintained in the files if FCCH evidencing compliance with the terms and conditions of the federal award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Corrective Action Plan: FCCH is retraining accounting and grants staff to promote understanding of the requirements of federal awards to include matching concepts. Policies and procedures shall be reviewed and updated to ensure supporting documentation is properly maintained in the files that evidence compliance with the terms and conditions of each federal award. Responsible Party: The CFO and Grants Director are responsible for ensuring compliance with grants that invoke matching principles. Reporting and documentation maintenance is also the responsibility of the CFO. The planned completion date for updating procedures and training staff is September 30, 2023.
FAC accepted this audit on December 15, 2020 — management decision was due June 15, 2021.
FAC accepted this audit on September 25, 2019 — management decision was due March 25, 2020.
FAC accepted this audit on September 30, 2018 — management decision was due March 30, 2019.
GSA_MIGRATION
Show full finding ▾Hide full finding ▴FAC accepted this audit on August 27, 2017 — management decision was due February 27, 2018.
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